Chapter 15 Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 Detailed Physical Examination  Primary objective: Discover all signs of injury that may not have been uncovered during the rapid trauma assessment

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4 Detailed Physical Examination  Goal of an EMT: Uncover those signs of injury that could not be treated while en route to the hospital

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 5 Detailed Physical Examination  Performed after the initial assessment and rapid trauma assessment have been completed  Measures the effectiveness of prehospital treatments that were initiated early in the assessment

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6 Detailed Physical Examination  May discover changes in the patient condition prompting an ALS intercept or change in priority of the patient  The detailed assessment is a methodical head-to-toe physical examination  Ongoing treatment of life-threatening conditions may preclude the completion of this examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 Steps in the Detailed Physical Examination  Very much like the rapid trauma assessment  DCAP-BTLS is used to describe the signs of injury that should be sought

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 8  Head –Palpate the entire skull, starting from the rear of the skull in the occipital area (look for DCAP-BTLS) –Remove glass shards that might cause injury Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 9  Ears –Look for DCAP-BTLS –Look for drainage; clear fluid might indicate cerebrospinal fluid CSF indicates a skull fracture Do not attempt to stop the flow of CSF, because doing so can result in increased pressure inside the skull –Check for Battle’s sign behind the ears, indicative of fracture to the base of the skull Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 10  Watch this video showing how CSF can leak from the ears Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 11  Eyes –Compare one eye to the other to examine for differences while looking for DCAP-BTLS –Bruising around the eyes is sometimes called raccoon’s eyes; it may be indicative of a fracture to the base of the skull Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 12  Eyes –Assess pupils for size, shape, and reaction to light –Lack of constriction in response to light may indicate serious eye or brain injury –Any foreign material such as dirt or glass should be brushed away from the eyes, if possible If it does not easily brush away, leave it alone and allow hospital staff to remove it Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14  Nose –Check for DCAP-BTLS –Excessive bleeding may result if a NPA is inserted into a broken nose –Check nares with penlight; blood running down the back of throat may nauseate the patient and cause vomiting –Clear fluid running from the nose may be CSF Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15  Face –EMT should next carefully assess the face for DCAP-BTLS Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16  Mouth –Injury can cause airway problem –Assess for DCAP-BTLS inside and outside the mouth –Check for loose teeth or other foreign objects and remove to prevent aspiration –Dental hardware should be removed if it is loose; otherwise leave it in place Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17  Mouth –Is the tongue swollen or the surrounding tissues reddened or discolored? –Swelling in the mouth from burns can mean swelling in the lower airways –Is voice hoarse after airway injury? Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 18  Neck –Assess for DCAP-BTLS –Determine position of trachea Midline or deviated? Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19  Chest –Should be thoroughly examined –Assess using DCAP-BTLS –Check breathing (observe for any difficulties or abnormalities); can the patient take a deep breath? –Listen to breath sounds (both anterior and posterior) Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21  Abdomen –Explain to the patient what you are doing –Look for any injuries indicated by DCAP-BTLS –Check for distension (may indicate internal bleeding) –Note urinary incontinence Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22  Abdomen –Listen to what the patient tells you –Where is the pain? Does one area of the abdomen hurt more than another? –Feel the anterior abdomen gently; does it feel soft? –A firm, tender abdomen indicates the natural muscular guarding of an injury; guarding may suggest abdominal bleeding Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 23  Abdomen –Don’t reassess areas where the patient has complained of abdominal pain or has shown signs of tenderness and guarding on previous physical exams –Little more can be gained from the information and the unnecessary creation of pain is cruel Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 25  Pelvis –Compression and flexion of pelvis –Pressing inward on the hips will help discover hip fracture –Press on the pubis to stress the bony pelvic ring –Tenderness during any part of this exam indicates possible fracture Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27  Extremities –Look for DCAP-BTLS –Palpate each limb along the length of the bone –Compare one extremity with another –Reassess for pulses, movement, and sensation (PMS) –Check grip strength and equality of grasp Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29  Vital signs revisited –Every exam should be followed up with a full set of vitals –Compare with baseline –Establish a trend –Any significant change in vital signs should be reported to the hospital staff Steps in the Detailed Physical Examination

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 30  Back and buttocks –Check back and buttocks for DCAP-BTLS –Carefully examine the back and buttocks for injury Do this while maintaining continuous manual stabilization of the head, preferably with a cervical collar in place Steps in the Detailed Physical Examination

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 32 Stop and Review  On whom should EMTs perform a detailed physical examination?  What is the primary objective of the detailed physical examination?  What are some of the things an EMT should check for when examining the head, ears, and eyes?